COMPLIANCE INFO_4/17/25 - Laserfiche WebLink

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Plan of Correction Deficiency Addressed: Improper disposal and labeling of biohazard waste, sharps, and pharmaceutical containers. 1. Immediate Corrective Action Taken: On 4/16/2025, the Director of Nursing (DON) completed rounds to ensure all clear bags were removed from treatment carts and replaced with red biohazard bags. The Environmental Services (EVS) Director confirmed that the correct bag sizes were available. The sharps container on the South Station medication cart was removed and replaced with a new, empty container. The responsible LVN received immediate education on avoiding co-mingling of waste (no solids in sharps containers). Additionally, a pharmaceutical container that was overflowing and another that was incorrectly labeled were both immediately replaced. All new pharmaceutical containers were placed with proper biohazard labeling on all four sides and the top. Licensed nurses were educated on avoiding overfilling pharmaceutical containers and ensuring lids remain secured at all times. 2. Action Taken to Identify Potential Deficiencies Elsewhere: The DON and Infection Prevention Nurse (IPN) conducted checks on all treatment carts facility- wide to confirm no clear bags were present. All pharmaceutical containers were reviewed for correct labeling and capacity status; all were found to need correction and were immediately addressed. Sharps containers on all medication carts were also checked; no co-mingled solid waste was found. 3. Measures Taken and Put Into Place to Maintain Systematic Changes: Licensed nurse staff were inserviced by the IPN on proper disposal of biohazard waste, including: - No use of clear bags in biohazard containers (red bags only) - Proper placement of biohazard labels (on all four sides and top of containers) - Correct disposal of IV medication bags and vials in pharmaceutical containers - Clarification that tubing and flush syringes are non-biohazard waste and can be disposed of in regular trash 4. Monitoring to Ensure Solution Is Sustained: The IPN will conduct weekly audits of all pharmaceutical containers, sharps containers, and biohazard waste containers on all treatment carts. Audits will check for: - Proper label placement - No co-mingling of solids in sharps containers - No overflowing pharmaceutical containers - Proper disposal of non-biohazard items such as tubing and flush syringes Findings will be reported to the Quality Assurance (QA) Committee for ongoing review and follow- up. 5. Alleged Compliance Date: May 7, 2025